528. Lab Stewardship for Clostridium difficile Testing Improves Appropriate Testing While Decreases Unnecessary Testing and Saves Laboratory Resources While Dramatically Helping to Reduce C diff Standardized Infection Ratios (SIR)

Abstract

BackgroundUnnecessary testing for Clostridium difficile infection (CDI) can be both wasteful and contra productive—retesting the same positive patient after transfer to a new nursing unit will only to confirm the patient has CDI (already known) and likely be classified as a new case of hospital-onset (HO) CDI. Yet, it is also important to recognize community-onset (CO) CDI in hospital, not only because it prevents late recognition of CO CDI as being classified as an HO event, will also to afford appropriate contact precautions and therapeutic measures are instituted in a timely fashion. Laboratory stewardship (LS) can be helpful in improving appropriateness of C. difficile testing.MethodsWe developed 2 CDI testing algorithms. One focused on hospital days 1–3, the other for all C. difficile testing after hospital day 3 (AHD3). The LS quality improvement (QI) project was rolled out in 2 stages. During the first 6 months we focused on improving early detection of CO-CDI, while during the next 6 months a mandatory review of all C. difficile testing orders AHD3 was conducted by a 10 person team. Testing that concurred with the algorithm was approved. Nonapproval was communicated to the care teams. Appeals could be made on a case-by-case basis to the medical director of infection control. Validation audits of nonapproved cases were performed to determine whether testing algorithms were sound.ResultsCO-CDI detection steadily increased over the yearlong LS QI period (average of 6 cases/week at start vs. 12 cases/week at year’s end). During the 6 months of the AHD3 mandatory order review 678 C. difficile orders were placed, 428 (63.1%) were approved, 250 (36.9%) were rejected. Reduced use of laboratory resources is estimated to have saved $14,950. LS and frequent communication with care teams contributed better recognition of CO-CDI, decreased inappropriate repeat testing, avoidance of diagnosing colonized patients as HO-CDI and was associated with a significantly drop our CDI SIR (Figure 1).ConclusionAn algorithm-based guideline for a 2-step LS QI program focused on reviews of all C. difficile orders AFHD3 as well as improving early detection of CO-CDI and was associated with better laboratory resource utilization and markedly decreased C. difficile SIR. Efforts are currently underway to automate much of the review process. Disclosures J. P. Parada, Merck: Speaker’s Bureau, Speaker honorarium. A. Harrington, Biofire: Grant Investigator and Scientific Advisor, Consulting fee, Research grant and Speaker honorarium. Cepheid: Grant Investigator and Speaker’s Bureau, Research grant.